Thursday, December 4, 2008

Will the renewed attention to primary care really change things?

Primary care is the flavor of the day. At least, that is what one might conclude from the flurry of articles, blogs, studies and reports that detail the crisis in primary care.

Jason Larkin writes in The Harvard International Review that Senator Tom Daschle, Obama's pick for secretary of Health and Human Services, is intrigued by the idea of creating a "national 'health corps, analogous to the Peace Corps ... [where] doctors finishing their training would be encouraged to do a year or two of domestic service in communities with uneven access to health care professionals.'" Larkin argues, though, that a "health corps should be part of a wider strategy to deal with one of the biggest problems in the American health system: the shortage of primary care physicians" citing ACP's recent white paper.

Paul Testa reflects in the New America Blog on a report by Karen Brown on NPR's All Things Considered about the troubles experienced by 440,000 newly-insured persons in Massachusetts in getting access to primary care doctors.

Victoria Knight writes in the Wall Street Journal Health Blog that it is "lack of access to primary care," not the uninsured, that is clogging up emergency rooms. She suggests that rather than "moving people into the hallways" a better solution is "better incentives for medical students who choose to go into primary care and more pay for physicians who work after hours." (The American College of Emergency Physicians, by the way, takes issue with the idea that "non-urgent" visits to emergency rooms are major factors in ER wait times).

As a good internist might say, awareness that there is a problem is the first step to curing it.

Yet I worry that there still is not the needed sense of urgency among key decision-makers. When I talk to staff on Capitol Hill, they acknowledge the need to do "something" for primary care. But then they add caveats: Where will the money come from? Won't the specialists object? It has to be "politically feasible."

Many don't yet seem to grasp that primary care won't be around much longer unless something big is done now to turn things around. Without a sense of urgency, we could end up with minimalist, non-controversial policies - small steps that are too little, too late, to save primary care.

Today's questions: Do you think your representatives, senators, patients, and neighbors understand the urgency of saving primary care? What are you doing to get them to understand?


Jay Larson MD said...

My Senator, Max Baucus, understands the primary care crisis and will be working on legislation in 2009 to help primary care docs. The question is...will it be enough. This raises a question. How much is enough to keep an internist in practice? How much should Medicare increase reimbursement for E and M, especially for typical internist patients? A 10% bonus has been mentioned. This would allow me to give my employees a 15 cent an hour raise and leave nothing for additional income.
Where will the additional funds to increase primary care reimbursement come from? It appears that no healthcare entity or organization wants to give up anything. Medicare is on a fast track to run out of funds and paying out more only increases the pace.
I have spent hours working on educating Senator Baucus and his Senate Finance Committee about the primary care crisis and the issues that need to be addressed to salvage primary care. The ACP White paper helped immensely to support the cause.
My patients are well informed by a self generated educational document "Save the Internist Campaign KIT" or STICK-IT for short.
You know, it is nice to finally be the flavor of the day. It is way overdue.

Scott Bolhack, MD said...

The primary care physician is not valued by society. The revenue stream is fraught with too many obstacles. The reasons for this are enumerated elsewhere by just about everyone over the past year. But what I have seen is that patients are also accessing health care differently too, and this trend will also continue. Why wait to see the primary care physician when there is essentially no barrier to health care (ER, urgent care, clinics in Walmarts and Walgreens, ad infinitum). The experience of the patient to work with a primary care physician will continue into the future for a small portion of the population; the rest will be able to research online the ballpark diagnosis and travel to easier access points to receive self-directed care. Few students will choose primary care; many of us will leave primary care in droves. The support structure will change as other entities (hospitals)that require primary care to survive will artificially support the profession.This is neither satisfying nor sustainable.

Walter Stonewall said...

I think that a very small percentage of the population understands the need for primary care. Nor do they understand that any type of health care system is dependent on primary care physicians.

The specialist has become the majority elite that Americans, a nation founded on choice, looks to for all their problems.

Specialists initially needed to invest large amounts of money for new technology and extended visits requiring increased compensations. Now technology has improved, efficiency has improved and specialists can see a large amount of patients with efficient procedures and technology. Compensation for the expertise and supremely efficient technology increased. Hence making specialists and specialized procedures extremely lucrative. The primary care doctor was left behind. They can increase efficiency and expertise but reimbursement is still mediocre at best. The gatekeeper of health care has been abandoned leaving only minimal pay and the same amount of school loan debt.

Students need to have an incentive to go into PC. Right now their is no incentive and their are very few doctors, PC or otherwise, who would ever recommend pursuing PC! Change! Change needs to occur NOW before the further collapse of health care arrives.

Repayment of student loans for PC, better reimbursement, and a marketing plan to advocate PC physicians and their skill set as a paramount roll to the United States citizens, United States wellbeing and the United States ability to adapt and innovate!

PCP said...

This issue is one of "doing the right thing" versus what "will the special interests think".
For some reason Our congressmen seem to have lost their ability to do something because it is in the broader national interest rather than an approach that preserves the status quo by threading the needle so as to accumulate the needed votes. This is most certainly not bold leadership. Hopefully Obama will provide bold leadership, but frankly Sen. Dashle's elevation to health secretary is somewhat scary.

Right now health care costs are strangulating the economy. Everyone seems to agree that we need to address that intelligently. And we have ample evidence that Internists deliver primary care for chronic illness that is not only extremely effective, but cost effective as well. Every one seems to agree that we deliver value to the system but noone wants to pay for it. We pay lip service to Value in healthcare, yet we complain about costs, we let wither arguably the best value in health care delivery through dumb antiquated policy for fear of what X and Y will think. All the while, our younger doctors are voting with their feet, because they are not dumb, yet we fiddle. This crisis can't be avoided, that train has already left the station with the choices of our graduating residents over the last 8-9 yrs, but by acting quickly we can contain it perhaps. Even to contain it we will need to act boldly and have strong leadership that can put the generalist along with the patient back in pole position at the very center of it all. All else must be secondary and serve this relationship. Only then will patients be more satisfied with the system and Generalists more engaged. There will be ample opportunities for others from NPs and PAs to Specialists around this core relationship. However neither side wants to accept that.
We are aware that we can not do it alone, the volume and complexity of medicine has become far too great for that and continues to grow, however right now our role is so minimised/marginalised by the system and we deeply resent that and our patients are lost.